Who is Eligible?
Medicare consists of two parts: Part A, which is hospital insurance, and Part B, which is medical insurance. Part A Benefits are provided free of charge to those 65 and older, or people receiving SSI or SSD for more than 24 months, and government employees (if they or their spouse worked ten years) disabled more than 29 months or those with kidney disease. Almost everyone with Part A coverage can get Part B for about $78.20 per month.
In New Jersey, there are several Medicare managed care plans that you may choose. If you choose one of these plans, the benefits and co-payments listed below may not apply.
PART A:Hospital Coverage
Medicare Part A covers in inpatient care for the Medicare recipient. Part A provides coverage for hospital care, skilled nursing care, home health visits and hospice care. Hospital care is provided for as follows :
• Patient is responsible for an $876.00 annual deductible;
• Days 1-60 Medicare pays 100% (after the $876.00 deductible);
• Days 61- 90 Medicare pays all charges in excess of $219.00 per day.
• Reserve: Days 91-150 Medicare pays charges in excess of $438.00 per day, but if you use up a reserve day, it is permanently lost. You have a total of 60 reserve days.
Benefit Period:
If you remain out of the hospital or skilled nursing home for 60 days in a row, a new 90 day benefit period begins.
Skilled Nursing Home - 100 days of care in each benefit period:
A. All covered skilled nursing services are paid by Medicare in the first 20 days.
B. Days 21 through 100: Medicare pays for covered skilled nursing services in excess of $109.50/day.
C. After 100 days, the individual is responsible for all nursing home charges.
To Qualify for Skilled Nursing Care: You must meet ALL of the following requirements:
• Have been in the hospital three days in a row prior to admission;
• Be transferred to the nursing home for a condition treated at the hospital;
• Be admitted to nursing home within 30 days after you leave the hospital;
• Doctor must certify you need skilled nursing or rehabilitation on a daily basis;
• The facility's Utilization Review Committee must not disapprove.
Home Health Visits:
Medicare will pay for home health visits up to 8 hours a day for 21 consecutive days, or longer if necessary, after discharge from hospital or skilled nursing home. To qualify for home health visits you must:
A. Require part-time skilled nursing care, physical or speech therapy;
B. Be confined to your home;
C. Your doctor must determine you need home health care and sets up a plan within 14 days of discharge from the hospital or skilled nursing facility;
D. Select a home health agency that participates in Medicare.
PART B:Medical Insurance Under Medicare
Open Enrollment is a seven month initial enrollment period, beginning three months before the month you are eligible for Medicare and ending three months after that date. A general enrollment period begins January 1st and ends March 31st each year, with coverage to be effective the following July.
Benefits: Medicare Part B pays 80% of all physician services in a doctor's office, at a hospital, at home and, after the $110.00 deductible is met, includes medical supplies and drugs as part of treatment. A secondary insurance or the individual will be responsible for any balance due after Medicare’s coverage. Outpatient hospital services in the emergency room or clinic for diagnosis and treatment falls under Medicare Part B.
Premium: Medicare recipients pay a premium of $78.20 each month for Part B benefits, which is generally deducted automatically from their gross Social Security benefits.
Doctor Participation: Doctors must either agree to accept Medicare payments for patients or refuse to accept Medicare payments for all patients. If the doctor agrees to accept Medicare payments for all patients, he is required to accept the fee which is preset by Medicare. He cannot charge an increased fee over this amount to the patient.
On the other hand, if a doctor refuses to accept assignment of Medicare benefits, he can charge the patient 15% over the prescribed figure set by the Medicare Program, up to a limit set by Medicare.
Amount of Benefits:
- Patient is responsible for a $110.00 annual deductible.
- Medicare will pay 80% of most Medicare approved charges, except:
a. Medicare pays 100% of approved clinical laboratory services;
b. Medicare pays 100% of approved home health services;
c. Medicare pays 100% for flu and pneumococcal pneumonia shots if the provider accepts assignment;
d. Medicare pays 80% of outpatient physical, occupational and speech- language therapy, subject to annual limits;
e. Medicare pays 50% for most outpatient mental health services.
The Medicare recipient or the recipient’s secondary insurance pays the balance of the charges.
Upcoming Benefits Under Medicare
The Medicare Prescription Drug Improvement and Modernization Act of 2003 was passed to strengthen and improve the Medicare program throughout the country. The Act adds new preventative benefits, prescription drug coverage and provides additional aide to individuals with low incomes.
Prescription Drug Benefits
Begun in the Spring of 2004, Medicare recipients have the option to enroll in a program designed to help save on prescription medications. The Medicare-Approved Drug Discount Card may entitle
cardholders to a savings of 10-25% on prescription drugs. If you already have prescription drug coverage under Medicaid, TRICARE for Life or an employer group health plan you cannot qualify for the credit.
Medicare’s regular prescription drug benefit will begin in 2006. You must already be enrolled in Medicare Part A or Part B to enroll in the Prescription Drug Plan and participation in the program is optional. The initial open enrollment period is expected to run from November 15, 2005 through May 15, 2006. Once the initial open enrollment has ended, you may enroll in the prescription drug program or change your plan during the annual enrollment period, which is expected to be November 15 - December 31 each year, coverage to be effective as of January 1 of the following year.
In January 2006, the Medicare prescription drug plans are expected to work as follows:
► Medicare recipient will choose a plan and pay a monthly premium of about $35, depending on which plan you choose;
► Recipient will be responsible for a $250 deductible;
► Medicare will cover about 75% of the costs between $250 and $2,250 for prescription drugs. The recipient will be responsible for the remaining costs;
► Recipient will be responsible for costs above $2,250 and up to $3,600 in out-of-pocket expenses;
► Medicare will pay about 95% of prescription drug costs above the $3,600 expended by the recipient. The recipient will be responsible for the balance.
Individuals with income below certain levels may not be responsible for the monthly premium or deductible amounts under the prescription drug program and would pay only a small coinsurance for each prescription. Other individuals with low income and limited assets may receive assistance in paying the premiums and the deductible, in addition to paying a limited amount for each prescription.
As with anything else, it would be wise to stay informed of any revisions to the laws, since the guidelines may change before the program is implemented.
Preventative Care Benefits
Beginning in 2005, in addition to the existing preventative benefits offered by Medicare, such as cancer screenings, bone mass measurements and vaccinations, Medicare will now cover several additional preventative measures.
New preventative benefits will include a one-time, initial physical exam to be performed within 6 months of enrolling in Medicare Part B, screening blood tests for the early detection of cardiovascular disease, and diabetes screening tests for those at risk for diabetes.
Specific information about the Medicare program may be obtained directly from Medicare by calling 1-800-MEDICARE.
For more information regarding these or other related subjects, please do not hesitate to call the Office of Michael Bolton, Esq. at (973) 425-0497.
